Exam #3 280
A nurse is teaching a child with type 1 diabetes mellitus how to self-inject insulin. Which method should she recommend to the child for regular doses?
Subcutaneously in the outer thigh Explanation: Insulin is always injected SC except in emergencies, when half the required dose may be given IV. SC tissue injection sites used most frequently in children include those of the upper outer arms and the outer aspects of the thighs. The abdominal SC tissue injection sites commonly used in adults can be adequate sites but most children dislike this site as abdominal skin is tender. Chapter 48: Nursing Care of the Child With an Alteration in Metabolism/Endocrine Disorder - Page 1912
A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?
Sweating, tremors, and tachycardia Explanation: Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia. Dry skin, bradycardia, and somnolence are signs and symptoms associated with hypothyroidism. Polyuria, polydipsia, and polyphagia are signs and symptoms of diabetes mellitus. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1482
A client with long-standing type 2 diabetes is surprised to see high blood sugar readings while recovering from an emergency surgery. Which factor may have contributed to the client's inordinately elevated blood glucose levels?
The stress of the event caused the release of adrenal cortical hormones. Explanation: Elevation of glucocorticoid levels (i.e., cortisol), such as during stressful events, can lead to derangements in glucose metabolism. Tissue trauma does not cause gluconeogenesis, and illness does not inhibit the action of glucagon. The dawn phenomenon is not a likely cause of the client's disruption in blood sugar levels. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1076
A 40-year-old woman comes to the clinic reporting having missed her period for two months. A pregnancy test is positive. What is she and her fetus at increased risk for?
placental abnormalities Explanation: A woman older than 35 years is more likely to conceive a child with chromosomal abnormalities such as Down syndrome. She is also at higher risk for spontaneous abortion (miscarriage), preeclampsia-eclampsia, gestational diabetes, preterm birth, bleeding and placental abnormalities, and other intrapartum complications. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 776
A woman in her 28th week of pregnancy tests positive for gestational diabetes mellitus and begins to follow a nutritional plan at home. What result at the follow-up visit indicates a successful outcome?
Random blood glucose 85 mg/dL (4.72 mmol/L) Explanation: The goals of the nutritional plan for gestational diabetes mellitus (GDM) include normal glucose levels, no ketosis, proper weight gain for the pregnancy, and adequate nutrition for fetal health. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 178
The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has?
Multiple myeloma Explanation: Any older adult with unprovoked or unexplained back pain and increased protein in the serum should be assessed for multiple myeloma. Bone pain occurs because of bone breakdown and the malignant cells of multiple myeloma increase the serum protein levels. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 994
A client has been diagnosed with multiple myeloma. Which of the following laboratory values should the nurse expect to find in a client with multiple myeloma?
Increased urinary protein Explanation: A characteristic finding in multiple myeloma is protein in the urine. Other laboratory findings include increased serum protein, hypercalcemia, anemia, and hyperuricemia. Polycythemia vera is not found in multiple myeloma. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 993
A 63-year-old woman has been diagnosed with polycythemia vera (PV) after undergoing a series of diagnostic tests. When the woman's nurse is providing health education, what subject should the nurse prioritize?
Lifestyle modifications and techniques for preventing thromboembolism Explanation: The increased blood volume and viscosity that are the hallmarks of PV create a significant risk of thromboembolism. A vascular access device is not necessary for the treatment of PV, and a low-iron diet does not resolve the disease. Patients may experience fatigue, but this risk is superseded by that of thromboembolism.
A 50-year-old woman was recently diagnosed with non-Hodgkin's lymphoma (NHL) and has begun a treatment regimen that includes simultaneous radiation therapy and chemotherapy. The combination of severe symptoms and aggressive therapy has necessitated admission to the hospital. When providing care for this patient, which of the following actions should the nurse implement?
Applying standard precautions conscientiously to reduce the patient's risk of infection Explanation: Treatment for NHL creates a significant risk of infection, a threat that must be minimized when planning and implementing nursing care. This is a priority over ADLs in the short term. The patient does not have a significantly increased risk of skin breakdown or constipation, although the nurse would assess for each problem.
The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis?
Polycythemia vera Explanation: Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. The other options do not have the characteristics of erythrocytosis. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 984
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?
Apply prolonged pressure to needle sites or other sources of external bleeding Explanation: For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
A nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should:
wash and inspect the feet daily. Explanation: A client with diabetes mellitus should wash and inspect his feet daily and should wear nonconstrictive shoes. Corns should be treated by a podiatrist — not with commercial preparations. Nails should be filed straight across. Clients with diabetes mellitus should never walk barefoot. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1495
A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate?
Below-normal serum potassium level Explanation: A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1486
The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for?
Bone pain in the back of the ribs Explanation: Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 994
A client has been recently diagnosed with type 2 diabetes, and reports continued weight loss despite increased hunger and food consumption. This condition is called:
polyphagia. Explanation: While the needed glucose is being wasted, the body's requirement for fuel continues. The person with diabetes feels hungry and eats more (polyphagia). Despite eating more, he or she loses weight as the body uses fat and protein to substitute for glucose. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1460
A 48-year-old female recently diagnosed with leukemia presents with increased immature lymphocytes, decreased granulocytes, and normal erythrocytes. The client most likely has which type of leukemia?
Chronic lymphocytic leukemia Explanation: Clients with CLL are typically older than 40 years of age, have increased immature lymphocytes, normal or decreased granulocytes, but erythrocyte and platelet counts may be normal or low. Clients with ALL are younger than 5 years of age; uncommon after 15 years of age. Clients with AML have a decrease in all myeloid formed cells: monocytes, granulocytes, erythrocytes, and platelets. Clients with CML are similar to those with AML but greater number of normal cells than in acute form.
Lispro (Humalog) is an example of which type of insulin?
Rapid-acting Explanation: Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus). Chapter 51: Assessment and Management of Patients With Diabetes - Page 1468
Which clinical manifestation of type 2 diabetes occurs if glucose levels are very high?
Blurred vision Explanation: Blurred vision occurs when blood glucose levels are very high. The other clinical manifestations are not consistent with type 2 diabetes. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1459
Which instruction about insulin administration should a nurse give to a client?
"Always follow the same order when drawing the different insulins into the syringe." Explanation: The nurse should instruct the client to always follow the same order when drawing the different insulins into the syringe. Insulin should never be shaken because the resulting froth prevents withdrawal of an accurate dose and may damage the insulin protein molecules. Insulin should never be frozen because the insulin protein molecules may be damaged. The client doesn't need to discard intermediate-acting insulin if it's cloudy; this finding is normal. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1477-1479
A young child develops type 1A diabetes. The parents ask, "They tell us this is genetic. Does that mean our other children will get diabetes?" The best response by the health care provider would be:
"This autoimmune disorder causes destruction of the beta cells, placing your children at high risk of developing diabetes." Explanation: Type 1 diabetes is subdivided into two types: type 1A, immune-mediated diabetes, and type 1B, idiopathic diabetes. Type 1A diabetes is characterized by autoimmune destruction of beta cells. The other choices are not absolutely correct. The fact that type 1 diabetes is thought to result from an interaction between genetic and environmental factors led to research into methods directed at prevention and early control of the disease. These methods include the identification of genetically susceptible persons and early intervention in newly diagnosed persons with type 1 diabetes. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1075
Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)?
A 72-year-old patient with a history of cancer Explanation: Primary MDS tends to be a disease of people older than 70 years. Because the initial findings are so subtle, the disease may not be diagnosed until later in the illness trajectory, if at all. Thus, the actual incidence of MDS is not known. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 982
The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has?
A general reduction in all white blood cells Explanation: Leukopenia is a general reduction in all WBCs. Leukopenia does not have anything to do with erythrocytes. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 970
The nursing instructor is talking with their clinical group about coagulopathies. How should the instructor define coagulopathies?
Coagulopathies are bleeding disorders that involve platelets or clotting factors. Explanation: Coagulopathies are bleeding disorders that involve platelets or clotting factors. Coagulopathies do not involve the numbers and types of red blood cells. They are not characterized by a deficiency of globulins in the plasma and they do not involve the destruction of stem cells in the bone marrow.
After hospital discharge, the parent of a child newly diagnosed with type 1 diabetes mellitus telephones the nurse because the child is acting confused and very sleepy. Which emergency measure would the nurse suggest the parent carry out before bringing the child to see the health care provider?
Give the child a glass of orange juice. Explanation: The child is experiencing symptoms of hypoglycemia. Administering a form of glucose would help relieve them. This can be glucose tablets or a rapidly absorbable carbohydrate such as orange juice. This should be followed by a snack of complex carbohydrates and protein within 30 to 60 minutes. Insulin cannot be absorbed when taken orally and administering insulin would make the hypoglycemia worse. Withholding treatment waiting to get to the health care provider's office may cause the hypoglycemia to worsen and be a risk to the child's life. Children with diabetes and their parents need to be taught to recognize and treat the symptoms of hypoglycemia. Chapter 48: Nursing Care of the Child With an Alteration in Metabolism/Endocrine Disorder - Page 1915
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?
Hypercalcemia Explanation: Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 994
A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition?
ketoacidosis Explanation: Kussmaul respirations (fast, deep, labored breathing) are common in ketoacidosis. Acetone, which is volatile, can be detected on the breath by its characteristic fruity odor. If treatment is not initiated, the outcome of ketoacidosis is circulatory collapse, renal shutdown, and death. Ketoacidosis is more common in people with diabetes who no longer produce insulin, such as those with type 1 diabetes. People with type 2 diabetes are more likely to develop hyperosmolar hyperglycemic nonketotic syndrome because with limited insulin, they can use enough glucose to prevent ketosis but not enough to maintain a normal blood glucose level. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1484
The nurse is discussing disorders of the hematopoietic system when a client asked about erythrocytosis. What disease will the nurse mention with a primary characteristic of erythrocytosis?
polycythemia vera Explanation: Polycythemia vera is associated with a rapid proliferation of blood cells produced by the bone marrow. In sickle cell disease, HbS causes RBCs to assume a sickled shape under hypoxic conditions. Aplastic anemia has a deficiency of erythrocytes. Sickle cell disease and the anemias do not have the characteristics of erythrocytosis. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 984
Which statement indicates that a client with diabetes mellitus understands proper foot care?
"I'll wear cotton socks with well-fitting shoes." Explanation: The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1495
A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with radiation therapy. In which complication do the donor's lymphocytes recognize the patient's body as foreign and set up reactions to attack the foreign host?
Graft-versus-host disease Explanation: Patients who undergo HSCT have a significant risk of infection, graft-versus host disease (in which the donor's lymphocytes [graft] recognize the patient's body as "foreign" and set up reactions to attack the foreign host), and other complications. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 973
The nurse is teaching a client about the development of leukemia. What statement should be included in the teaching plan?
"Chronic leukemia develops slowly." Explanation: Chronic leukemia develops slowly, and the majority of leukocytes produced are mature. Acute leukemia develops quickly and the majority of leukocytes are undifferentiated cells. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 971
A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response?
"Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy." Explanation: Ketones (or ketone bodies) are by-products of fat breakdown in the absence of insulin, and they accumulate in the blood and urine. Ketones in the urine signal an insulin deficiency and that control of type 1 diabetes is deteriorating. When almost no effective insulin is available, the body starts to break down stored fat for energy. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1467
A client's primary care provider has ordered an oral glucose tolerance test (OGTT) as a screening measure for diabetes. Which instruction should the client be given?
"The lab tech will give you a sugar solution and then measure your blood sugar levels at specified intervals." Explanation: The OGTT measures the plasma glucose response to 75 g of concentrated glucose solution at selected intervals, usually 1 and 2 hours. A fasting blood glucose test requires 8 hours without food, and A1C measures glucose binding to hemoglobin. A casual blood glucose test is administered without regard for time or last meal. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1074 - 1075
A 3-year-old girl has just been diagnosed with type 1A diabetes. Her parents are currently receiving education from the diabetes education nurse. How can the nurse best explain to the parents the etiology (cause) of their daughter's diabetes?
"The problem that underlies her diabetes is that her own body has destroyed the cells in her pancreas that produce insulin." Explanation: Type 1A, or immune-mediated, diabetes involves the autoimmune destruction of pancreatic beta cells and a consequent absolute lack of insulin. Exogenous insulin is required as dietary control alone is insufficient. The central problem is an absolute lack of insulin production rather than deranged release. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1075-1076
Following an oral glucose tolerance, a 36-year-old mother of 4 has been diagnosed with gestational diabetes mellitus (GDM), a problem that was not present in any of her previous pregnancies. What should her primary care provider tell her about this new health problem?
"Your baby could become too large or have low blood sugars if we're not vigilant about controlling your sugars." Explanation: Women with GDM are at higher risk for complications of pregnancy, mortality, and fetal abnormalities. Fetal abnormalities include macrosomia, hypoglycemia, hypocalcemia, polycythemia, and hyperbilirubinemia. GDM often persists as type 2 diabetes after delivery. The baby does not face a significantly higher risk of developing diabetes. Nutrition therapy would precede insulin therapy and GDM involves a pancreatic etiology. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1078
A client hospitalized with type 1 diabetes has been administered a scheduled dose of regular insulin. What are the primary actions of insulin? Select all that apply.
-Fat storage -Glucose uptake by muscle and adipose tissue -Protein synthesis Explanation: There are three actions of insulin: (1) it promotes glucose uptake by target cells and provides for glucose storage as glycogen; (2) it prevents fat and glycogen breakdown; and (3) it inhibits gluconeogenesis and increases protein synthesis. Glucagon, not insulin, promotes glycogenolysis. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1075
A nurse must recognize the duration of insulin as to not cause harm to the client with administration of the improper type of insulin. Which insulins are long-acting insulin? (Select all that apply.)
-Insulin glargine (Lantus) -Insulin detemir (Levemir) Explanation: Insulin glargine (Lantus) and insulin detemir (Levemir) are long-acting insulins with a duration of 24 hours. Chapter 38: Agents to Control Blood Glucose Levels - Page 642
A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?
Assess for signs of injury. Explanation: A client with hypoesthesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection. Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 998
A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention?
Assess the client's hemoglobin and platelets. Explanation: Clients with AML may develop pallor from anemia and a tendency to bleed because of a low platelet count. Assessing the client's hemoglobin and platelets will help to determine whether this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 972
An otherwise healthy 33-year-old woman experienced debilitating and persistent fatigue over a period of several weeks and was subsequently diagnosed with acute myeloid leukemia (AML). The woman has been admitted to the hospital for treatment. The nurse who is providing care for this patient should prioritize which of the following assessments?
Assessing the woman for signs and symptoms of infection Explanation: Infection and bleeding present the greatest risks to patients with AML. As a result, nursing assessments related to these problems should be prioritized over cardiac status and fluid balance. The patient is at a low risk of thromboembolism.
A client is admitted with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which laboratory finding should the nurse expect in this client?
Blood glucose level 1,100 mg/dl Explanation: HHNS occurs most frequently in older clients. It can occur in clients with either type 1 or type 2 diabetes mellitus but occurs most commonly in those with type 2. The blood glucose level rises to above 600 mg/dl in response to illness or infection. As the blood glucose level rises, the body attempts to rid itself of the excess glucose by producing urine. Initially, the client produces large quantities of urine. If fluid intake isn't increased at this time, the client becomes dehydrated, causing BUN levels to rise. Arterial pH and plasma bicarbonate levels typically remain within normal limits. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1486
A client with acute myeloid leukemia (AML) receiving chemotherapy is treated for an acute renal injury. What is the nurse's best understanding of the pathophysiological reason behind the client's injury?
Chemotherapy causes an increase in kidney stone formation. Explanation: Massive leukemic cell destruction from chemotherapy results in the release of intracellular electrolytes and fluids into the systemic circulation. This causes an increase in uric acid levels, potassium, and phosphate (also known as tumor lysis). The increase in uric acid predisposes the client to the development of kidney stones and increases the risk for renal injury. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 973
A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will receive?
Induction therapy Explanation: Despite advances in understanding of the biology of AML, substantive advances in treatment response rates and survival rates have not occurred for decades, with the exception of advances made in treating APL (see later discussion). Even for patients with subtypes that have not benefited from advances in treatment, cure is still possible. The overall objective of treatment is to achieve complete remission, in which there is no evidence of residual leukemia in the bone marrow. Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 972
When administering insulin, what would be most appropriate?
Insert the needle at a 45-degree angle for injection. Explanation: The vial should be gently rotated and vigorous shaking is to be avoided to ensure uniform suspension of the insulin. Typically the area is pinched to allow access to the loose connective tissue layer. The needle is inserted at a 45-degree angle for subcutaneous administration. Gentle pressure should be applied at the injection site. Chapter 38: Agents to Control Blood Glucose Levels - Page 641
Which statement is correct regarding glargine insulin?
It cannot be mixed with any other type of insulin. Explanation: Because this insulin is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. There is no peak in action. It is approved to give once daily. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1468
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms?
Multiple myeloma Explanation: The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 994
The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer?
NPH Explanation: Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or Lente insulin. Lispro (Humalog) is rapid acting, Iletin II is short acting, and glargine (Lantus) is very long acting. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1468
A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever?
Neutropenia Explanation: Fever and infection result from a decrease in neutrophils (neutropenia). Decreased red blood cells (anemia) cause weakness, fatigue, dyspnea on exertion, and pallor in AML. Pancytopenia, an overall decrease in all blood components, is not cause of fever in clients with AML. Decreased platelet count (thrombocytopenia) causes petechiae and bruising in AML. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 972
The nurse is interviewing the caregivers of a child admitted with a diagnosis of type 1 diabetes mellitus. The caregiver states, "She is hungry all the time and eats everything, but she is losing weight." The caregiver's statement indicates the child most likely has:
Polyphagia Explanation: Symptoms of type 1 diabetes mellitus include polyphagia (increased hunger and food consumption), polyuria (dramatic increase in urinary output, probably with enuresis) and polydipsia (increased thirst). Pica is eating nonfood substances. Chapter 48: Nursing Care of the Child With an Alteration in Metabolism/Endocrine Disorder - Page 1911
The nurse recognizes the clinical assessment of a patient with acute myeloid leukemia (AML) includes observing for signs of infection early. What nursing action will most likely help prevent infection?
Practice vigilant handwashing. Explanation: Infection prevention is best handled by vigilant handwashing. Monitoring the client's temperature once a shift is not often enough. The client will take precautions, but precautions are enough to prevent infections. Encouraging increased fluid consumption will not prevent infection. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 972
A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client?
Preventing bone injury Explanation: When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict fluid intake. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 997
A client with multiple myeloma presents to the emergency department and reports excessive thirst and constipation. Family members report that the client has been confused for the last day. Which laboratory value is most likely responsible for this client's symptoms?
Serum calcium level 13.8 mg/dl Explanation: Excessive thirst, constipation, dehydration, confusion, and altered mental state are possible signs of hypercalcemia. Hypercalcemia is common in multiple myeloma because of the increased bone destruction. A platelet count of 300,000/mm3 is normal and wouldn't cause the client's symptoms. A sodium level of 133 mEq/L is slightly decreased but wouldn't cause confusion and excessive thirst. A hemoglobin of 9.8 g/dl level is slightly low but isn't likely responsible for the client's symptoms. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 994
Research has identified a cycle of insulin-induced posthypoglycemic episodes. What is this phenomenon called?
Somogyi effect Explanation: The Somogyi effect describes a cycle of insulin-induced posthypoglycemic episodes. In 1924, Joslin and associates noticed that hypoglycemia was associated with alternate episodes of hyperglycemia. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1081
Which term is used to refer to a primitive cell that is capable of self-replication and differentiation?
Stem cell Explanation: Stem cells may differentiate into myeloid or lymphoid stem cells. A band cell is a slightly immature neutrophil. A spherocyte is a red blood cell without central pallor. A reticulocyte is a slightly immature red blood cell. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 970
The health care provider is assessing a new client who is reporting nonintentional weight loss. The provider should consider which potential diagnosis?
Type 2 diabetes Explanation: Some people with undiagnosed type 2 diabetes may experience unexplained weight loss as cellular resistance to circulating insulin reduces energy availability. If one's blood pressure is extremely high, there may be certain symptoms to look for, including severe headache; fatigue or confusion; vision problems; chest pain; difficulty breathing; and irregular heartbeat. Signs of adrenal tumor include high blood pressure; low potassium level; heart palpitations; nervousness; feelings of anxiety or panic attacks; headache; excessive perspiration; and diabetes. Warning signs of an eating disorder like anorexia include dramatic weight loss; lying about how much and when one has eaten; avoiding eating with others; cutting food into small pieces; and trying to hide how thin one is by wearing loose or baggy clothes. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1076
A nurse is providing teaching to a client who will undergo chemotherapy and radiation prior to hematopoietic stem cell transplantation (HSCT) for acute myeloid leukemia (AML). What statement will the nurse use to describe the purpose of the chemotherapy and radiation?
"These therapies destroy the ability of your body to produce blood cells inside your bone marrow." Explanation: The treatment goal of chemotherapy and radiation therapy is the destruction of hematopoietic function of the client's bone marrow. The client is then "rescued" with the infusion of the donor stem cells to reinitiate blood cell production. AML is a cancer of the blood and does not have a mass effect/tumor that other cancers may cause. Also, these therapies are not used to decrease a client's pain or to decrease the risk of allergic reaction. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 973
A client is brought to the emergency department with a suspected diagnosis of DKA (diabetic ketoacidosis). Select the assessment data (or diagnostic data) to confirm the diagnosis. Select all that apply.
-Low serum bicarbonate -Positive urine ketones Explanation: The definitive diagnosis of DKA consists of hyperglycemia (blood glucose levels >250 mg/dL [13.8 mmol/L]), low serum bicarbonate, low arterial pH, and positive urine and serum ketones. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1080
A client presents to the emergency room with fatigue, weakness, dehydration, and thirst. What additional symptoms would correlate with a diagnosis of type 1 diabetes mellitus? Select all that apply.
-Recent weight loss -Polyuria -Blurred vision Explanation: The cardinal manifestations of diabetes mellitus are the three "polys": polyuria, polydipsia, and polyphagia, and weight loss. Additional symptoms include fatigue and weakness, blurred vision, and skin infections. Chapter 41: Disorders of Endocrine Control of Growth and Metabolism - Page 1075
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
10 to 15 g of a simple carbohydrate Explanation: To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. Then the client should check his blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1482
The nurse is educating the client with diabetes on setting up a sick plan to manage blood glucose control during times of minor illness such as influenza. Which is the most important teaching item to include?
Increase frequency of glucose self-monitoring. Explanation: Minor illnesses such as influenza can present a special challenge to a diabetic client. The body's need for insulin increases during illness. Therefore, the client should take the prescribed insulin dose, increase the frequency of glucose monitoring, and maintain adequate fluid intake to counteract the dehydrating effects of hyperglycemia. Clear liquids and juices are encouraged. Taking less than normal dose of insulin may lead to ketoacidosis.
A client newly diagnosed with type 1 diabetes asks the nurse why the client cannot just take a pill. The nurse would incorporate what knowledge when responding to this client?
Insulin is needed because the beta cells of the pancreas are no longer functioning. Explanation: Insulin is needed in type 1 diabetes because the beta cells of the pancreas are no longer functioning. With type 2 diabetes, insulin is produced, but perhaps not enough to maintain glucose control or the insulin receptors are not sensitive enough to insulin. Chapter 38: Agents to Control Blood Glucose Levels - Page 634
A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing goal?
Maintain nutrition. Explanation: Maintaining nutrition is the most important goal after induction therapy because the client experiences severe diarrhea and can easily become nutritionally deficient and develop fluid and electrolyte imbalance. The client is most likely not in pain at this point, and this is an intervention, not a goal. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 973
The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order?
Reflects the amount of glucose stored in hemoglobin over past several months. Explanation: Hemoglobin A1c tests reflect the amount of glucose that is stored in the hemoglobin molecule during its life span of 120 days. This test provides a more accurate picture of overall glucose control in a client. Glycosylated hemoglobin test does not indicate normal blood functioning or nutritional state of the client. Self-monitoring with a glucometer is still encouraged in clients who are taking insulin or have unstable blood glucose levels. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1467
A nurse is caring for a client with type 1 diabetes who exhibits confusion, light-headedness, and aberrant behavior. The client is conscious. The nurse should first administer:
15 to 20 g of a fast-acting carbohydrate such as orange juice. Explanation: This client is experiencing hypoglycemia. Because the client is conscious, the nurse should first administer a fast-acting carbohydrate, such as orange juice, hard candy, or honey. If the client has lost consciousness, the nurse should administer I.M. or subcutaneous glucagon or an I.V. bolus of dextrose 50%. The nurse shouldn't administer insulin to a client who's hypoglycemic; this action will further compromise the client's condition. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1481
A pregnant woman diagnosed with diabetes should be instructed to perform which action?
Notify the primary care provider if unable to eat because of nausea and vomiting. Explanation: During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia. Chapter 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations - Page 738
The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures?
Osteoclasts break down bone cells so pathologic fractures occur. Explanation: The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. The other options are distractors for this question. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 994
The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take?
Perform a neurologic assessment with vital signs. Explanation: With platelets less than 10,000/mm³ there is a risk for spontaneous bleeding, including within the cranial vault. The nurse performs a neurologic examination to assess for this possibility. Though the client is receiving immunosuppressants, it is not necessary to use contact precautions with this client. Contact precautions are used with clients who have known or suspected transmittable illnesses. Diphenoxylate and atropine can cause constipation and inhibit accurate assessment of the client's gastrointestinal bleeding. If the client strains when having a bowel movement, the client could bleed even more. The client is not to floss vigorously; doing so can cause bleeding. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 973
The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about?
Platelet count of 9,000/mm3 Explanation: Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency (thrombocytopenia). The low platelet count can cause ecchymoses (bruises) and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 972
A patient with a diagnosis of immune thrombocytopenic purpura (ITP) is currently receiving IVIG for the treatment of her health condition. The nurse who is providing this patient's care is aware that ITP is a consequence of:
Platelet destruction and impaired platelet production resulting from an autoimmune process Explanation: Although the precise cause of ITP remains unknown, the platelet count is decreased by a combination of autoantibody-mediated platelet destruction and impaired platelet production secondary to autoantibody effects on the megakaryocyte. Viruses, impaired liver function, and inappropriate platelet aggregation are not dimensions of the etiology of ITP. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 554
What is the only insulin that can be given intravenously?
Regular Explanation: Insulins other than regular are in suspensions that could be harmful if administered IV. Chapter 51: Assessment and Management of Patients With Diabetes - Page 1471-1472
A client with multiple myeloma reports severe paresthesia in the feet. When planning care for the client, which priority nursing diagnosis will the nurse choose?
Risk for falls Explanation: A client with paresthesia in the feet is at risk for falls due to impaired sensation. Acute pain, impaired tissue integrity, and sensory-perception disturbance are all nursing diagnoses that are appropriate for the client; however, risk for falls is priority. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 998
A client with suspected multiple myeloma is reporting back pain. What is the priority nursing action?
Send the client for a spinal x-ray study. Explanation: The client with myeloma can have bone pain, especially in the back and ribs. The pain will decrease with rest and increase with activity. Lying on a hard surface will not relieve the pain. The priority action is to make certain the client does not have a fractured spine, as the bone destruction in this disease is sufficiently severe to cause vertebral collapse. Chapter 34: Management of Patients With Hematologic Neoplasms - Page 994
The diabetic client asks the nurse why shoes and socks are removed at each office visit. Which assessment finding is most significant in determining the protocol for inspection of feet?
Sensory neuropathy Explanation: Neuropathy results from poor glucose control and decreased circulation to nerve tissues. Neuropathy involving sensory nerves located in the periphery can lead to lack of sensitivity, which increases the potential for soft tissue injury without client awareness. The feet are inspected on each visit to insure no injury or pressure has occurred. Autonomic neuropathy, retinopathy, and nephropathy affect nerves to organs other than feet.
